Financial Affidavit Short Form

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INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 
 12.902(b), FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM)(10/11)
 	
When should this form be used? 
This form should be used when you are involved in a family law case which requires a  financial 
affidavit  and your individual gross income is UNDER $50,000 per year  unless.

The  affidavit  must  be  completed  using  monthly income  and  expense  amounts.  If  you  are paid 
or  your  bills  are  due  on  a  schedule  which  is  not  monthly,  you  must  convert  those  amounts. 
Hints are provided below for making these conversions. 
Hourly  - If  you  are  paid  by  the  hour,  you  may  convert  your  income  to  monthly  as 
follows: 
Hourly amount  x  Hours worked per week  = Weekly amount 
Weekly amount  x  52 Weeks per year  = Yearly amount 
Yearly amount  ÷  12 Months per year  =  Monthly Amount 
Daily  - If you are paid by the day, you may convert your income to monthly as follows: 
Daily amount  x  Days worked per week  = Weekly amount 
Weekly amount  x  52 Weeks per year  = Yearly amount 
Yearly amount  ÷ 12 Months per year  =  Monthly Amount 
Weekly  - If  you  are  paid  by  the  week,  you  may  convert  your  income  to  monthly  as 
follows: 
Weekly amount  x  52 Weeks per year  = Yearly amount 
Yearly amount  ÷ 12 Months per year  =  Monthly Amount 
Bi -weekly  - If  you  are  paid  every  two  weeks,  you  may  convert  your  income  to  monthly 
as follows: 
Bi -weekly amount  x  26 = Yearly amount 
Yearly amount  ÷ 12 Months per year  =  Monthly Amount 
Semi -monthly  - If  you  are  paid  twice  per  month,  you  may  convert  your  income  to 
monthly as follows: 
Semi-monthly amount x  2 =  Monthly Amount 
Expenses may be converted in the same manner. 
Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer  helps you fill 
out  these  forms,  that  person  must  give  you  a  copy  of  a  Disclosure  from  Nonlawyer,  Florida 
Family  Law  Rules  of  Procedure  Form  12.900(a),  before  he  or  she  helps  you.  A  nonlawyer 
helping you fill out these forms also  must put his or her name, address, and telephone number 
on the bottom of the last page of every form he or she helps you complete. 	
Instructions to Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)  ( 10/11 )

IN THE CIRCUIT COURT OF THE  JUDICIAL CIRCUIT, 
IN AND FOR  COUNTY, FLORIDA 
Case No.: 
Division: 
,
 
Petitioner,
 
and
 
, 
Respondent. 
FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM)  (Under $50,000 Individual Gross Annual Income)
 
I,  {full legal name}
  ,  being  sworn,  certify  that  the 
following information is true: 
My Occupation:  Employed by: 
Business Address: 
Pay rate: $  ( ) every week (  ) every other week (  ) twice a month (  ) monthly 
(  ) other: 
___  Check  here  if  unemployed  and  explain  on  a  separate  sheet  your  efforts  to  find 
employment. 
SECTION I.  PRESENT MONTHLY GROSS INCOME: 
All amounts must be MONTHLY.  See the instructions with this form to figure out money 
amounts for anything that is NOT paid monthly.  Attach more paper, if needed.  Items included 
under “other” should be listed separately with separate dollar amounts.

SECTION II.  AVERAGE MONTHLY EXPENSES               E.  OTHER EXPENSES NOT LISTED ABOVE
    
A.	  HOUSEHOLD:  Clothing $ _______ 
Mortgage or rent  $  _______ Medical/Dental (uninsured) $ _______ 
Property taxes  $ _______ Grooming  $ _______ 
Utilities  $_______  Entertainment  $ _______ 
Telephone   $ _______  Gifts  $_______ 
Food  $ _______  Religious organizations  $ _______ 
Meals outside home  $ _______ Miscellaneous  $ _______ 
Maintenance/Repairs  $ _______  Other: ______________  $ _______ 
Other: __________	  $______ _  ____________________  $ _______ 
____________________  $ _______ 
B.	  AUTOMOBILE  ____________________  $_______ 
Gasoline  $ _______  ____________________  $ _______ 
Repairs  $_______  ____________________  $ _______ 
Insurance  $_______ 
C.	  CHILD(REN)’S EXPENSES  F.  PAYMENTS TO CREDITORS 
Day care  $ _______  CREDITOR:  MONTHLY
 
Lunch money  $ _______  PAYMENT
 
Clothing  $ _______
 
Grooming  $_______  ____________________  $ _______ 

Gifts for holidays  $ _______  ____________________  $ _______ 

Medical/Dental (uninsured) $  _______ ____________________  $
_______
 
Other:  $_______
  ____________________  $
_______ 
____________________  $ _______ 
D.	  INSURANCE 
____________________  $ _______ 
Medical/Dental  $ _______ 

Child(ren)’s medical/dental  $ ____ ___  ____________________  $
_______ 

____________________  $ _______ 
Life	  $ _______ 
____________________  $ _______ 
Other:  $ _______ 
____________________  $ _______ 
____________________  $ _______ 
 
28.  $_______  TOTAL MONTHLY EXPENSES  (add ALL monthly amounts in A through F above) 
SUMMARY

A. ASSETS:
 
DESCRIPTION  OF  ITEM(S).  List  a  description  of  each  separate 	item 	
owned by you (and/or your spouse, if this is a petition for dissolution 
of marriage). LIST ONLY LAST 4 	DIGITS OF ACCOUNT NUMBERS. Check 	
the  box 	next  to  any  asset(s)  which  you 	are  requesting  the  judge 	
award to you. 	
Current Fair Market Value 	
Nonma	rital 	
(Check 	correct 	
column) 	
husband 	wife 	
Cash (on hand) 	$ 	
Cash (in banks or credit unions) 
Stocks, Bonds, Notes 
Real estate: (Home) 
(Other) 
Automobiles 
Other personal property 
Retiremen	t plans (Profit Sharing, Pension, IRA, 401(k)s, etc.) 	
Other 
Check 	here 	if additional pages are attached. 	
Total Assets 	(add next column) 	$ 	
B. LIABILITIES:
 
DESCRIPT	ION  OF  ITEM(S).  List  a  description  of  each  separate  debt 	
owed  by  you  (and/or  your  spouse,  if  this  is  a  petition  for  dissolution 
of marriage). LIST 	ONLY LAST 4 	DIGITS OF 	ACCOUNT NUMBERS. 	Check 	
the  box  next  to  any  debt(s)  for  which  you  believe  you  should  be 
responsible. 	
Current Amount Owed 	
Nonmarital 
(check 	correct 	
column) 	
husband 	wife 	
Mortgages on real estate: First mortgage on home 	$ 	
Second mortgage on home 
Other mortgages 
Auto loans 
Charge/cr	edit card accounts 	
Other 	
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (10/11)

DESCRIPT	ION  OF  ITEM(S).  List  a  description  of  each  separate  debt 	
owed  by  you  (and/or  your  spouse,  if  this  is  a  petition  for  dissolution 
of marriage). LIST 	ONLY LAST 4 	DIGITS OF 	ACCOUNT NUMBERS. 	Check 	
Current Amount Owed 	
Nonmarital 
(check 	correct 	
column) 	
the  box  next  to  any  debt(s)  for  which  you  believe  you  should  be 
responsible. 	husband 	wife 	
Check 	here if additional pages are attached. 	
Total Debts 	(add next column) 	$ 	
C.	  CONTINGENT ASSETS AND LIABILITIES: 
INSTRUCTIONS:  If you have any  POSSIBLE assets (income potential, accrued vacation or sick 
leave,  bonus,  inheritance,  etc.)  or  POSSIBLE  liabilities (possible  lawsuits,  future  unpaid 
taxes, contingent tax liabilities, debts assumed by another), you must list them here. 	
Contingent Assets 	
Check 	the box next to any contingent asset(s) which you are 	
requesting the judge award to you. 	
Possible Value 	
Nonmarital 
(chec	k correct 	
column) 	
husband 	wife 	
$ 	
Total Contingent Assets 	$ 	
Contingent Liabilities 	
Check 	the 	box next to any contingent debt(s) for which you believe 	
Possible Amount 	
Nonmarital (check 	correct 	column) 	
you should be responsible. 	Owed 	
husband 	wife 	
$ 	
Total Contingent Liabil	ities 	$ 	
SECTION IV.  CHILD SUPPORT GUIDELINES WORKSHEET 
(Florida  Family  Law  Rules  of  Procedure  Form  12.902(e),  Child  Support  Guidelines  Worksheet, 
MUST  be  filed  with  the  court  at  or  prior  to  a  hearing  to  establish  or  modify  child  support.  This 
requirement cannot be waived by the parties.) 
[Che ck one  only] 
____  A Child Support Guidelines Worksheet IS or WILL BE filed in this case.  This case 
involves the establishment or modification of child support. 
____  A Child Support Guidelines Worksheet IS NOT being filed in this case.  The 
es tablishment or modification of child support is not an issue in this case. 
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (10/11)

I  certify  that  a  copy  of  this  document  was  [choose  only  one]  ( 
mailed (  ) hand delivered to the person(s) listed below on  {date} )  mailed  ( 
)  faxed  and 
. 
Other party or his/her attorney: 
Name: 
Address: 
City, State, Zip: 
Fax Number:  I  understand  that  I  am  swearing  or  affirming  under  oath  to  the  truthfulness  of  the 
claims made in this affidavit and that the punishment for knowingly making a false statement 
includes fines and/or imprisonment. 
Dated:  Signature of Party
 
Printed Name: 

Address:
 
City, State, Zip:
 
Telephone Number:
 
Fax Number:
 
STATE OF FLORIDA 
COUNTY OF 
Sworn to or affirmed and signed before me on  by . 
NOTARY PUBLIC or DEPUTY CLERK 
[Print,  type,  or  stamp  commissioned  name 
of notary or deputy clerk.] 
____  Personally known 
____  Produced identification 
Type of identification produced 
IF  A  NONLAWYER  HELPED  YOU  FILL  OUT  THIS  FORM,  HE/SHE  MUST  FILL  IN  THE  BLANKS 
BELOW:  [fill in all blanks] 
I,  {full legal name and trade name of nonlawyer}  , 
a nonlawyer, located at  {street}  , {city}  , 
{state}  , {phone}  , helped {name}  , 
who is the [choose only  one] petitioner or  respondent, fill out this form. 	
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (10/11)